ICD编码质控对于编码正确率的影响  

Influence of ICD Coding Quality Control on Coding Accuracy

作　　者：郑伟伟 郭明霞[1] Zheng Weiwei;Guo Mingxia(Department of Medical Records,People's Hospital of Zhengzhou,Zhengzhou,450003,Henan Province,China)

机构地区：[1]郑州人民医院,河南省郑州市450003

出　　处：《中国病案》2022年第7期13-16,共4页Chinese Medical Record

摘　　要：目的 通过对某院住院病案首页ICD编码开展抽样质量控制,分析编码质量缺陷的原因并提出整改措施,旨在持续提高编码质量。方法 2020年12月15日-2021年2月25日期间,5位编码员采用判断抽样的方法对住院病案首页疾病诊断、手术及操作的ICD编码进行交叉质控,每位编码员每周至少抽取50份住院病案首页,每2周为1个质控周期,持续进行了3个周期,共质控1616份,存在575份ICD编码质量缺陷病案,用Excel 2007对缺陷情况进行描述性统计分析。结果 ICD编码质量缺陷率为35.58%,3个质控周期缺陷率逐步下降,依次为40.91%、37.20%、27.4%,P均小于0.05,质控前后差异具有统计学意义。编码质量缺陷构成中,前3位依次是手术及操作漏编(19.13%)、其他诊断错编(14.43%)、主要诊断错编(12.7%)。编码质量缺陷原因为编码员专业能力(89.22%)和临床医师书写习惯(10.78%)。结论 ICD编码质控有助于提升编码正确率。编码员需积极参加编码培训与交流,熟练掌握编码规则,主动查阅工具书,加强与临床医师的沟通等;临床医师应养成良好的病案书写习惯,规范化填写住院病案首页;医院还应加强病案系统信息化建设,辅助编码员和临床医师共同提升编码正确率。Objectives This study aims to analyze the causes of coding quality defects and put forward some rectification suggestions through sampling quality control of ICD coding on the medical record front pages from a hospital,in order to keep improving the coding quality on the medical record front pages.Methods From December15,2020 to February 25,2021,five coders used the method of judgment sampling to conduct cross quality control on the disease diagnoses on the front pages of inpatient medical records,surgical operations and operations on ICD codes.Each coder sampled at least 50 inpatient medical record front pages every week.Every two weeks was a quality control cycle,and the whole sampling period lasted for three cycles.A total of 1616 inpatient medical record front pages went through quality control,among which 575 medical records had ICD coding quality defects.These medical records with coding defects were analyzed by descriptive statistics with Excel 2007.Results The ICD coding quality defect rate was 35.58%.The defect rates decreased gradually in the three quality control cycles,which were40.91%,37.20%and 27.4%.P value was less than 0.05 and the difference was statistically significant.In the composition of coding quality defects,the top three factors were operation omission (19.13%),other diagnostic errors (14.43%) and main diagnostic errors (12.7%).89.22%of the coding quality defects was caused by the professional ability of coders and 10.78%was caused by the writing habits of clinicians.Conclusions The quality control of ICD coding helps improve improve the coding accuracy.Coders need actively participate in coding training and communication,master coding rules,consult reference books,and strengthen communication with clinicians.Clinicians should develop a good habit of writing medical records and standardize their writings on the front pages of inpatient medical records.Hospitals should also strengthen the information construction of medical record system and assist coders and clinicians to improve improve

关 键 词：住院病案首页 质量监控 ICD编码 

分 类 号：R197.323[医药卫生—卫生事业管理]